Provider Demographics
NPI:1902814312
Name:NLJ PHYSICAL THERAPY CENTER P.C.
Entity Type:Organization
Organization Name:NLJ PHYSICAL THERAPY CENTER P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT OF CLINIC
Authorized Official - Prefix:MR
Authorized Official - First Name:NEAL
Authorized Official - Middle Name:LORN
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:LICENSED PHYSICAL TH
Authorized Official - Phone:906-774-3779
Mailing Address - Street 1:901 PYLE DRIVE
Mailing Address - Street 2:
Mailing Address - City:KINGSFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49802-4452
Mailing Address - Country:US
Mailing Address - Phone:906-774-3779
Mailing Address - Fax:906-774-6712
Practice Address - Street 1:901 PYLE DRIVE
Practice Address - Street 2:
Practice Address - City:KINGSFORD
Practice Address - State:MI
Practice Address - Zip Code:49802-4452
Practice Address - Country:US
Practice Address - Phone:906-774-3779
Practice Address - Fax:906-774-6712
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-03
Last Update Date:2011-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501003258208100000X
WI4326024208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
380747012OtherTRICARE NORTH
1009687OtherPREFERRED ONE
650012048OtherRAILROAD MEDICARE
650B257010OtherBCBS OF MICH
0P30190Medicare ID - Type Unspecified